(A) The provider shall have written policies and procedures regarding the purchasing, receipt, storage, distribution, return, and destruction of medication that include accountability for and security of prescription and over-the-counter medications located within any of its facilities. These policies and procedures shall include, but not be limited to the requirements that providers handling medications shall:
(1) Hold a valid and current terminal distributor of dangerous drugs license from the Ohio board of pharmacy if maintaining a stock supply of prescription medications or if participating with the department's central pharmacy to receive dispensed prescriptions.
(2) Locate all medications and prescription blanks in a locked, secure area;
(3) Designate a person having access to or authorized to handle medication and shall maintain a current list of these persons, their credentials and their medication handling responsibilities.
(4) Provide a method to record and follow the medications from the time of receipt to the time of distribution, return to central pharmacy, or destruction. This record shall be retained by the provider for three years and shall include, but not be limited to the following information:
(a) The date and time the medication was received by the provider, distributed to persons served, returned to central pharmacy or, if appropriate, destroyed;
(b) The name , credentials and signature of all persons handling the medications; and
(c) The provision that unused medication prescribed for a person shall be appropriately destroyed or returned to central pharmacy, and that, under no circumstances shall the unused medication be issued to another individual. Return of unused medication prescribed to a person is only allowed when the return is to central pharmacy in accordance with rule 4729-9-04 of the Administrative Code .
(5) Ensure that all staff handling medications have basic and ongoing instruction and training in safe and effective handling of medications.
(6) Ensure that medications are handled only by authorized persons and that others do not have access to the medications; and
(7) Ensure that controlled substances may be destroyed only by an agent of the Ohio board of pharmacy, or the federal drug enforcement agency, or by transfer to persons registered under Chapters 3719. and 4729. of the Revised Code and according to rule 4729-9-06 of the Administrative Code.
(B) Providers maintaining a limited stock supply of medications shall:
(1) Allow only a physician or pharmacist to dispense medication, although the following individuals may personally furnish samples of some medications if issued a certificate to prescribe:
(2) Have visibly posted the phone number of the nearest poison control center.
(C) Each provider that permits clients to self-administer medication shall have written policies and procedures that include, but are not limited to, the following:
(1) Procedures for storing medications in a locked cabinet.
(2) Procedures for self-medication.
(3) Procedures for accounting for medications that are kept for the client while they are at the program site.
(4) Policy prohibiting clients from having unsecured prescription medications in their possession at the provider site or while involved in activities off site unless required for medical necessity, e.g. prescription inhalers for persons with asthma.
(5) Procedures for obtaining and for accounting for medications (prescription and over-the-counter) from clients at the time of admission to or upon entering the provider site and return of same, as appropriate, at the time of the discharge or departure.
(D) The provider shall have a policy on employee drug theft and shall inform all employees concerning this policy. The policy shall include attention to prescription as well as over-the-counter medications maintained for client use.
(1) An employee, intern or volunteer with knowledge of drug theft by an employee or any other person shall report such information to the executive director of the provider. If the executive director of the provider is suspected of drug theft, the employee or volunteer shall notify the department.
The provider shall take all reasonable steps to protect the confidentiality of the information and the identity of the person furnishing the information.
(2) Suspected drug theft shall be reported to the Ohio board of pharmacy. For controlled substances, suspected drug theft shall also be reported to the federal drug enforcement administration. Providers participating in drug services with the Ohio department of mental health and addiction services central pharmacy shall also notify central pharmacy.
(3) Failure to report information of drug theft shall be considered in determining the eligibility of the employee to continue to work in a secure area where drugs are stored.
(4) If an employee violates the provider's drug theft policies, the provider shall assess the seriousness of the employee's violation, whether the violation has a direct and substantial relationship to that employee's position, the past record of employment, and other relevant factors in determining whether to suspend, transfer, terminate, or take other action against the employee.
Five Year Review (FYR) Dates: 06/29/2015 and 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 1/1/91, 10/1/93, 7/1/2011